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Final Exam > Periop Med > Flashcards

Periop Med Flashcards

1
Q

PERIOP MED (Psych/drugs) - Methamphetamines

[20B11] Discuss the perioperative implications for a patient known to use methamphetamine.

A

Mimic - endogenous monoamines (sympathomimetic) –> excitation and euphoria

  1. CVS
    - Sympathomimetic
  2. Resp
    - smoking +/- PHTN
  3. Metabolic
    - Hyperthermia
    - Met acidosis
    - rhabdo
    - malnutition

Acute vs chronic use

Chronic
- withdrawal, dependence, comorbidities

Hx
- drug / duration
- comorbidities

Ex
- intox

Ix
- viral
- ECG - long QT

consent? aggression –> BZD?

INTRAOP
1. BP - labile -
2. Aim euvolaemia

Postop
- monitor withdrawal - sleep/eat/depress
- psych / A&D

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2
Q

MAKE UP

[-] Discuss the perioperative implications for a patient known to use CANNABIS (instead of methamphetamine.)

A

SAD - substance abused disorder

CNS-depressant
- EtOH
- BZD
- opioids

CNS-stim
- cocaine
- amphetamines
- ecstasy
- CBD

Aim
1. Prevent w/d effective analgesia
2. Sx Rx of affective/behavioural problems

Key
1. Acute (consent) vs chronic use (poor nutrition, comorbid)
2. Difficult IV access
3. PPE
4. Post op analgesia plan

Natural vs synthetic
Oral vs pulm

Low bioavail
Long t1/2
Low tox

CBD

PM10 2019: Medicinal cannabis for chronic pain
OHA p.337

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3
Q

PERIOP MED (Neuro) – Parkinson’s disease

[21A06] You will be anaesthetising a 63-year-old man with severe Parkinson’s disease who is booked for an inguinal hernia repair. Discuss the issues that are relevant to providing perioperative care for this patient. (also 15A10, 09A05)

A

RTB
rigidity/tremor/bradykinesia

AUTONOMIC/cog/emo

Pathophys
ACh (exc) and DA (inh) imbal in BG –> loss of DA–> unopp EXC –> tremor/rigid

Drugs
- Levodopa
- Carbidopa
- DA agonist
- MAO-Bi
- COMTi
- Anti-ACH
- NMDA antag

Features
1. Cog change
2. Autonomic instability
3. Aspiration risk
4. Meds
- continue Da drugs
- avoid anti-Da )
Post op - return to meds

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4
Q

PERIOP MED (Neuro) – Myasthenia gravis

[20B09] A patient with myasthenia gravis presents for emergency laparotomy for small bowel obstruction.
Discuss your perioperative management of this patient including your choice of anaesthesia. (also 14B09, 06A05, 03B03)

A

MG
IgG autoab + POST-syn nAChR at NMJ

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5
Q

PERIOP MED (Neuro) – Peri-operative stroke

[19B13] List the risk factors for perioperative stroke. (50%)
Discuss the measures you use to ̄ perioperative stroke in high-risk patients undergoing major orthopaedic surgery. (50%) (also 12A13)

A

RF
patient:
1. Age > 70yo
2. F
3. Comorbin
Intraop
1. Type (cardiac/CEA)
2. Urgency (emerg > elec)
3. GA>RA>LA
4. Duration

Post op
1. AMI/AF
2. Dehyd
3. Hypergly

Periop Mx to dec stroke
1. Pre op
-

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6
Q

PERIOP MED (Neuro) – Traumatic SC transection at C6 (acute)

[15A14] A 40-year-old requires a laparotomy ten days after an isolated traumatic spinal cord transection at C6.
1. Outline the key anaesthetic issues. (50%)
2. How would these influence your anaesthetic management? (50%)

A

Key
1. Unstable C-spine
2. Neurogenic shock
3. Acute laparotomy

Neurogenic
- loss ANS
- dec BP, dec HR, peri VD

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7
Q

PERIOP MED (Neuro) – Longstanding C5-6 quadriplegia

[13B15] A 25-year-old female with longstanding C5-6 quadriplegia requires ureteric stent insertion. Outline the implications for anaesthesia.

A
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8
Q

PERIOP MED (Neuro) - Epilepsy

[13A05] What are the perioperative concerns for the anaesthetist managing a patient with epilepsy?

A

Epilepsy - common 1%
Anti-epileptic

Anaes agent ~ seizures
- IV - avoid etom/ket
- VA - avoind enf
- Opioid - avoid peth/tram
- NMBA - avoid sux(K up)/laudanosine from atrac
- LA - re ceiling dose

CYP450
Carb/pheny - indu
Valp - inhibit

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9
Q

PERIOP MED (GI) – Liver

[10B03] A 45-year-old man with a longstanding history of alcoholism is booked for upper gastrointestinal endoscopy and banding of oesophageal varices following an episode of haematemesis.
(a) How is the severity of this patient’s liver disease assessed? (50%)
(b) How do these findings influence your evaluation of this patient’s perioperative risk? (50%)

A

Liver scoring
1. MELD
- BIC - bili/INR/Cr
2. CP
- A/B/P/E/C

Extra-hepatic sequelae
1. HRS
2. HPS

Type/urgency of procedure

Type of anaes require

Comorbid

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10
Q

PERIOP MED (Haem) – von Willebrand disease

[19A13] Outline your approach to the perioperative management of a patient who gives a strong family history of von Willebrand disease.

A

Types of vWD (ISTH)
Quant def: 1 and 3
Qual def: 2

Mx Responder vs non-responder
Rx - DDAVP (desmo)
*rel vWF
Mx options
Mx - diff types of vWD

Features
1. 2050 a.a. plasma glyco
2. 1% AD chr 12mut
3. mucosal bleed

Rx:
1+2a - DDAVP
2b+3 - vWF replacement

Cryo - IIIF(fibronectin, fibrinogen, vWF), FVIII, FXIII
*F8/vWF = Humate P

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11
Q

PERIOP MED (Haem) – Anaemia 1

[19A10] These are the blood results of a 65-year-old man scheduled for a revision total hip replacement.
- Interpret these results (30%)
- How would you manage this patient preoperatively? (70%)

A

DDx
Micro/Normo/Macro
1. Hb
2. MCV - M/N/M

  • IDA
  • Ferritin <30
  • Non-IDA
  • Ferritin > 100

Optimise

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12
Q

PERIOP MED (Haem) – Minimising blood loss and transfusion

[15B03] An adult patient is scheduled for a major operation during which significant blood loss is expected. Describe strategies you would consider perioperatively when planning to minimise blood loss and transfusion requirement.

A

Key strategies PBM
*1. Mx anaemia
*2. Min BL
*3. Imp tol to anaemia

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13
Q

PERIOP MED (Haem) - VTE

[15A12] In PAC, you are assessing a patient who is concerned about the risk of developing venous thromboembolism (VTE) perioperatively.

a) Outline the patient factors that increase the risk of VTE. (50%)

b) Describe measures that may reduce the risk of perioperative VTE (50%)

A

(83.4%) Candidates were expected to at least mention
- a) Previous history/family, obesity, cancer and oestrogen containing pills
- b) Measures would include minimising the preop, intraop and postoperative risks
Background
(also 08B05, 05A02)

RF = virchows triad
Stasis, hypercoag, endo dam

Mx
1. Preop
a. STRATIFY

  1. Intraop
    a. GCS
    b. IPC
    c. Pharm
  2. Postop
    a. Mob early
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14
Q

PERIOP MED – Addison’s disease

[21B08] Discuss how a diagnosis of Addison’s disease would influence your perioperative management of a patient who requires an urgent laparotomy for bowel obstruction.

A

Addison dx
- hypoTension
- low cortisol (GC) and aldosterone (MC)

Effect (add crisis from stress)
1. BGL low
2. Na low
3. K High
4. Urea high

Mx
1. Fludrocort
2. Hydrocort (GC+MC)

Preop
- C - consult endocrine

Intraop
1. IAL for BP monitoring
2. Electrolytes - Na/K
3. Steroid cover
- Hydrocortisone
- Dex 6-8mg - good for 24h
x dex - no MC activity

Post op
1.

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15
Q

PERIOP MED (Endocrine) – T2DM

[19A03] a) List the causes of increased perioperative morbidity and mortality in surgical patients with type 2 diabetes mellitus. (30%)

b) Outline the principles of perioperative management of these patients. (70%)..

(also 17A05, 09B02, 06A03)

A

Key
1. HbA1c <8.5% (postop if > 9)
2. BSL perio op: 5-10mmol/L

Perio

Meds
1. OHA - WH DOS
2. SGLT-2 - WH 2/7 prior + DOS
- If Ket > 1 and pH < 7.3/ HCO3 < 15 –> ivf + ins/dex

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16
Q

PERIOP MED (Endocrine) – T2DM + autonomic neuropathy

[16B14] A 45-year-old male with long standing diabetes is scheduled to undergo elective laparoscopic cholecystectomy.
a) In the preanaesthesia assessment clinic, how would you assess this patient for the presence of diabetic autonomic neuropathy? (50%) b) Discuss the anaesthetic implications of his autonomic neuropathy. (50%) (also 11A15, 05B03)

A

AN
- DM, PD etc

Ax (AUTONOMIC NEUROPATHY)

CVS
* Hydrostatic hypotesnvie

GI
- Gastroparesis -

GU
- impotence
- retention

Thermoreg
- loss of sweating

b) Implications
*Impaired BRR + inability to inc HR –> fixed CO

Intraop
- IDC
- preload
- pre-emp vasopressor
- resp++ to laryngoscopy
- asp risk

Post op
- silent ischaemia

17
Q

PERIOP MED (Endocrine) – T2DM + HTN

[13B01] A 68-year-old man is scheduled for total knee replacement next week.

He has hypertension, for which he is prescribed enalapril, and type 2 diabetes, for which he is prescribed metformin.

Justify your perioperative management of his medications.

A
  1. Periop Risk strat
  2. Maintain “normal”
  3. GL+RECOMM!!
  4. Risk/Ben calc

General
1. Withdrawal
2. Disease progress
3. Interaction with anaes
4.

Controlled?
Omit both DOS

Consider
1. Anxiolytic - avoid stress
2. Intraop HTN - clon/hydral
3. Intraop BGL - freq measure + insulin inf
4. Resume meds ASAP post op

18
Q

PERIOP MED (Endocrine) - Carcinoid syndrome

[18B11] Discuss your perioperative management of a patient with carcinoid syndrome presenting for small bowel resection.

A

sx by NE tumour secreting VASOACTIVE subs
- triad - heart/diahhoea/flushing

PREMED Rx - octreotide
50mcg/hr IV 12hr preop

Intraop
- Prop/Remi

Conflicts:
- RSI vs titr ind
- RSI vs avoid sux
- deep anes vs CV dysfx

POSTOP:
ICU/HDU - vol/elec/bsl/HD
wean octreotide

19
Q

PERIOP MED (Endocrine) - Thyroidectomy

[17B08] Discuss the preoperative assessment for a patient who presents for thyroidectomy.

A

Mass effect, potential AW problems, adj structures, endocrine issues

Mass effect
1. AW
2. SVC return

20
Q

PERIOP MED (Endocrine) - Acromegaly

[14A13] A 53 year-old man with acromegaly presents for a transphenoidal resection of his pituitary tumour.
a) Outline the features of acromegaly. (50%)
b) How does this diagnosis influence your anaesthetic management? (50%) (also 08A12)

A

Acro features

Heart + AW

DM/HTN/LVH/OSA
DHLO 30405060%

Dx:
1. Inc IGF-1
2. GH supp test

Rx:
1. Sx - pit macroadenoma
2. Adj. SOMATOSTATIN analogue
3. GH-r ANTAG (pegvisomat) (nonresp)
4. Pit irradiation

Pre:
1. AW ax
2. visual ax
3. OSA
4. CVS

Intraop
1. Secure DA
2. Crisis
a) post op stridor
b) endo emerg: DI, SIADH
3. Difficult access + IAL
- positioning
- HTN
- VAE

Postop
1. HDU/ICU
2. Upper CN signs
3. Hormonal supp - ?hydrocort
4. CSF leak, DI

21
Q

PERIOP MED (Autoimmune, congenital, acquired) – Rheumatoid arthritis

[20A15] Discuss the anaesthetic considerations for an adult patient with rheumatoid arthritis presenting for wrist surgery. (also 02A10)

A

Key
1. RA severity
2. CVS/Resp involv
3. Meds
4. AA instab/AW consideration
5. Regional
6. Positioning
7. Analgesia

*DO NOT overcall

RA
- auto-infla
- symmetrical polyarthritis
- extra art involv

CR involvement

Current meds - DMARDS
steroids - >10mg = cover
MTX - ILD, hep fail
SSZ - neutro/thrombopaenia, IPF
AZA - hepatitis, BM supr

XR - ANT arch of atlas TO odontoid process > 3mm = AAS ***

Ix
1. TTE if sig SOB at rest
2. ABG if SpO2 < 95% RA or O2 Rx
3. Resp Ex + –> PFT + CXR

Intraop
1. RA > GA
2. Prep for DA, min C spine manip
3. Positioning

Post op
1. suitable for day surg
2. HDU/ICU if concerns
3. restart reg meds ASAP
4. multi modal
5. OT - hand fx important

22
Q

PERIOP MED (Autoimmune, congenital, acquired) – Marfan Syndrome

[19B03] Discuss how Marfan syndrome influences your anaesthetic management for a patient requiring an urgent laparoscopic appendicectomy.

A

Key
1. CVS ~ BP control - laryngoscopy, pneumo and ext
2. AW issues
3. Lung path - avoid PTX 2o bullae

Marfan
- AD CT metab
- fibrillin 1 gene on chr 15

  • ## stiff aortic walls
23
Q

DASI and METS

A

VO2 peak (mL/kg) = 0.43 × DASI + 9.6

DASI 34 –> 24

METs (metabolic equivalents) = VO2 peak / 3.5

24
Q

PERIOP MED (Autoimmune, congenital, acquired) - Frailty

[19A11] Define frailty and discuss the role of prehabilitation for patients with frailty.

A

Frailty
- multidimensional
- depletion of physiological reserve
- vulnerable to stress
- harder to recover from illness
- independent RF for higher M&M
- “CLINICAL FRAILTY SCALE”

Prehab
- enhancing fx cap
- withstand stressor
- improve baseline + shorten recovery

4 approach
1. Med optimise
2. Phys exercise
3. Nutritional support
4. Psych support

Benefits (theoretical)
- improbve CR fx
- dec LOS, post op pain, post op comp

Limitations
1. limited evidence
2. variation/no std protoc
3. Cost
4. Var compliance

Prehabilitation

https://academic.oup.com/bjaed/article/17/12/401/4083340

25
Q

PERIOP MED (Autoimmune, congenital, acquired) - Scleroderma

[17B09]
A 50-year-old woman with systemic sclerosis (scleroderma) presents for laparoscopic appendicectomy.

She is currently treated with folate supplements and weekly methotrexate.

Describe how your anaesthetic plan is modified by the presence of scleroderma in this patient.

A

Key
1. Avoid aspiration
2. potential DA (limited MO)
3. Safe vent strategy
4. Difficult monitoring

26
Q

PERIOP MED (Autoimmune, congenital, acquired) – Cystic fibrosis

[17A02] A 24-year-old female with cystic fibrosis is scheduled to undergo elective breast surgery.
How does the presence of cystic fibrosis affect your perioperative management of this patient for this procedure?

A
27
Q

PERIOP MED (Autoimmune, congenital, acquired) – Myotonic dystrophy

[16A02] A 30-year-old patient with myotonic dystrophy is scheduled for surgery for acute appendicitis.

a) Outline the important factors in the preoperative assessment of this patient. (50%)

b) Describe how this patient’s myotonic dystrophy will affect your anaesthetic management. (50%)

A

RESP ISSUES

*RLD + OSA

Myotonia = prolonged muscle contraction

Dystrophy = muscle wasting

Dystonia = atrophy + contraction
DM (1 - chr 19; 2 - chr 3) and MC

Muscle dystrophy = progressive weakness
INHERITENCE
Main = x linked = DMD and Becker

CF
Systems
1. AW/Resp = bulbar, RLD
2. CVS = CM , MCP
3. GI = delayed motility –> ASPIR

Anaes
1. Sux - X - K+ myo contracture
2. Sens to CNS depress
3. Neo - X - Myo cont

28
Q

PERIOP MED (Psych/drugs) – Cease smoking

[16A11] As a perioperative physician, what strategies can you offer to assist a patient to cease smoking tobacco and how will you best communicate them? (also 09B14)

2 parts to the Q

A

(79%) Borderline standard: To achieve a pass candidates needed to describe a reasonable non- pharmacological intervention that is effective in the medium to long term AND have a grasp of at least one suitable replacement therapy.

  1. Non-pharm intervention Med/long term
    a. Indiv counselling
    b. GBT
    c. rapid smoking aversive therapy
  2. Replacement therapy
    NRT - patch/gum/strips
  3. Pharm
    NrPA - varenicline
    Bupropion
    Nortriptyline
    Clonidine

Communicate
AAR - ask/advice/refer

Benefits

PG12(POM) Perioperative smoking 2014

29
Q

Smoking Cessation Benefits

Whic PG?

A

1 day = low COHb
3 weeks = improve skin healing
6mo = imm fx

PG12(POM) Perioperative smoking 2014

30
Q

PERIOP MED (Psych/drugs) – Chronic alcohol misuse.

[15B12] A 47 year old man presents to the emergency department with acute abdominal pain requiring a laparotomy.

He is known to have chronic high intake of alcohol.

Describe how chronic alcohol misuse will affect your perioperative management of this patient.

A

BG

Pre
Hx

Intra
RSI likely
Inc anaes req
HD instab likely

Post
Post op del
post op w/d
Analgesia

31
Q

PERIOP MED (Other) – POSSUM Score, SORT score

[20A04] The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the Surgical Outcome Risk Tool (SORT) are examples of risk scoring systems used for predicting postoperative morbidity and mortality.

Evaluate the strengths and weaknesses of these types of risk scoring systems in clinical practice.

A

POSSUM
- 2 part
- 12 phys var
- 6 op var
- 16-136
- 30 day M&M rate

SORT (2011)
- UK, non cardiac/NROS/obs/txp
- 30 day M&M
- 6 perop var

Strength of SCORING SYS in gen:
1. Better than clinical judgement alone
2. Allows shared decision making with patient and surgeon
3. Improved preoperative planning

CONS
1. Not predictive for the individual patient
2. May not apply to your specific hospital or population
3. SUBJECTIVE data points

Additional (Bluebook 2023)
Ideal
1. High acc
2. Good disc
3. Good cali
4. Local validated

  1. Wide applicability
  2. Versatile
  3. Simple to use
  4. Parsimonius
  5. Transparent/explainable
  6. Regularly pdated
  7. Compliance
32
Q
A

Therapeutic GC
1. Hydrocort ~ cortisone
2. prednisolone
3. DEX

  1. Hydrocortisone 100mg then 200mg/24hrs
  2. Dex 6-8mg (good for 24 hrs)

Guidelines for the management of glucocorticoids during
the peri-operative period for patients with adrenal
insufficiency
Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK

Anaesthesia 2020

Final Exam (28 decks)

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